T&O - Femoral And Tibial Shaft Fractures And Knee Injuries Flashcards
Femoral and tibial shaft fractures: initial Mx points
- Must resuscitate pt and deal with life threatening injuries first (X match units of blood)
- Assess neurovascular status, especially distal pulses
Femoral and tibial shaft fractures: Rx
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Intramedullary nail and/or plate and ex-fix
- *Sub trochanteric NOF fractures are not treated with DHS (intertrochanteric are Rx with DHS) and must be treated like a midshaft fracture - with intramedullary nail and screws
- If open fracture: start ABX, take pt to theatres for debridement and washout
Femoral and tibial shaft fractures: specific complications/risks
- Hypovolaemic shock
- Neurovascular: sciatic nerve damage, swelling
- Compartment syndrome
- Respiratory complications: fat embolism, ARDS, pneumonia
Ankle fractures: what rules do you use?
Ottawa ankle rules
Suspect ankle fracture and perform X-ray if:
- Pain in malleolar (lat or med) zone
- Tenderness along distal 6cm of posterior tib/fib including posterior tip of malleoli
- Inability to weight bear both immediately and in ED
Knee injuries: common presentations
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Swelling:
- Immediate: haemarthrosis = torn cruciates
- Hours later OR overnight (effusion = meniscus or other ligament tear)
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Pain:
- Meniscal: along joint line, on straightening knee
- vs med/lar margins (collateral ligs)
- Locking: meniscal tear and obstruction
- Giving way: instability following ligament injury
Knee haemarthrosis: causes of primary or secondary bleeding
- Primary:
- Spontaneous bleeding - warfarin, haemophilia
- Secondary:
- Trauma - ACL injury, patella dislocation, meniscal injury, osteophyte fracture
Knee injuries: mechanisms of injury
- Collateral ligaments: torn in valgus or varus strains
- MCL caused by valgus strain on outside of leg
- LCL caused by varus strain
- Twisting injuries: lead to meniscus tears or a rupture of the ACL
- Hyperextension injuries: Ruptured PCL
Knee injuries: unhappy triad
Torn medial meniscus, ACL and MCL
Mx of acutely injured knee
- Full examination of acutely swollen knee is very difficult
- Take X-ray to ensure no fracture
-
If no fracture:
- RICE + later re-examination for pathology
- MRI if meniscal/crucifer injury suspected
Dislocation of patella: MOI and Mx
MOI: blow to side of knee causes lateral dislocation of patella
Mx of 1st time traumatic dislocation is conservative unless there is osteochondral fracture or medial patellar stabilisers
- Reduce patella and put in POP for 3 weeks
- Short cast time with early mobilisation with or without brace and with physio
Fractures of patella: name different ways in which the patella can fracture
- Communited: direct blow, likely to also have damage in underlying femoral condyles - try to reduce and fix, avoid taking patella out
- Transverse fracture of patella: violent contracture of quads against resistance - usually town in two horizontally - open reduction and early mobilisation
Name a few inflammatory conditions affecting the knee
- Cysts of menisci: usually arises from lateral meniscus, enlarges under capsule, forms a swelling which is tense in certain positions of flexion. Is liable to tear, in which removal of meniscus is better than cyst removal.
- Other causes: OA/RA, ankylosis spondylitis, gout
Bursitis in the knees: what are the bursae that can become inflamed in the knee?
Infrapatellar bursitis - Clergyman’s
Suprapatellar Bursitis
Pre-patellar bursitis - Housemaid’s
Bursitis in knees: Mx and Rx
Septic bursitis
- Admit pt if systemically unwell, is immunocompromised, severe infection in surrounding tissue or has other comorbidities such as RA and diabetes.
- Will probably need IV ABX
Primary care Mx of bursitis
- RICE and modify activities which worsen symptoms -Compression
- Analgesia: paracetamol/NSAIDs
- Can aspirate fluid if uncomplicated septic bursitis is suspected OR there is very big swelling
Degenerative conditions knee: popliteal cysts
Popliteal cysts: common all ages, painless swellings in popliteal fossa, often fluctuate in size
- Only excise if cause other symptoms
- Larger/diffuse cysts associated with pathology of knee joint (RA esp)
- Should address/look at underlying cause, can do synovectomy/dissection of cyst
What is the commonest joint to get OA?
Knee
Pathology of OA in the knee
Caused by extensive wearing away of joint cartilage, fraying of menisci, marginal osteopaths and some synovial thickening (but little inflammation)
- Primary: no obvious underlying cause
- Secondary: follows pre-existing abnormality of joint (fracture, RA, haemarthrosis, meniscal tear, etc)
Joints affected: hips, knees, DIPs, PIPs, thumb and CMC
Symptoms of OA in knee
- Pain
- Stiffness
- Deformity
Pain pattern: worse with movement and at the end of the day. (RA is early morning stiffness)
Ix for OA in knees
- Bloods: CRP may be mildly elevated + Ca/PO4 and ALP all normal
- X-ray changes:
- Decreased joint space
- Osteophytes
- Subchondral sclerosis
- Bone cysts
- Evidence of previous disorders (rheumatoid/congenital defects), structural damage (late sign)
Rx for OA in knees: Conservative and surgical
Conservative methods
- Losing wt, using stick, modifying work, analgesics and NSAIDs, physio, heat
Surgical Rx:
- Arthroscopic lavage/debridement: controversial
- Osteotomy: esp in younger pts, aims to correct abnormal bone alignment
- Arthroplasty: knee replacement - most common operation for knee OA, can be total or part
Ruptured ACL: specific Mx
- Conservative: rest, physio to strengthen quads and hamstrings, not enough stability for many sports
- Surgical: autograph repair (gold standard - usually semitendinosus +/- gracilis)
- tendon threaded through heads of tibia and femur and held using screws.
Knee injuries: Tests
- Meniscal Tears: Thessaly’s test - weight bearing at 20 degrees of knee flexion, patient
- Ruptured PCL: Paradoxical anterior draw test
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